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Incident report
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* Indicates required question
Name of person involved
*
Your answer
*
Student
Intern
Advisor
Visitor
Staff
Other:
Required
Type of Incident
*
Behavioral
Accident
Illness
Theft
Property Damage
Other:
Name(s) of witness(es)
Your answer
Date of occurrence
*
MM
/
DD
/
YYYY
Time of occurrence
*
Time
:
AM
PM
Describe the sequence of activity in detail including what the person(s) was/were doing at the time:
*
Your answer
Reported incident to: (name)
*
Your answer
Where occurred? (Specify location, including location of witness(es))
*
Your answer
Was injured participating in an organized YEBW activity at time of injury?
*
Yes
No
Maybe
What could the injured have done to prevent injury?
*
Your answer
Emergency procedures followed at time of incident/accident
*
Your answer
By whom?
*
Your answer
What followup (if any) is needed?
Your answer
This report submitted by:
*
Your answer
Position:
*
Advisor
Intern
Staff
Nurse
Other:
Date
*
MM
/
DD
/
YYYY
Phone Number
*
Your answer
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